JBFahey 3-2010 SEIZURES Jean B. Fahey MSN, RN, ACNS-BC, CCRN, CNRN Neuroscience Clinical Nurse Specialist Massachusetts General Hospital Boston, MA

JBFahey 3-2010JBFahey 3-2010

SEIZURESSEIZURESJean B. Fahey MSN, RN, Jean B. Fahey MSN, RN, ACNS-BC, CCRN, CNRN ACNS-BC, CCRN, CNRN

Neuroscience Clinical Nurse Neuroscience Clinical Nurse Specialist Specialist

Massachusetts General HospitalMassachusetts General HospitalBoston, MABoston, MA


Nature of seizures & epilepsyNature of seizures & epilepsy

Incidence, risk factorsIncidence, risk factors

Brain anatomy and pathophysiologyBrain anatomy and pathophysiology

Classification of seizure typesClassification of seizure types

Signs and symptoms of seizures Signs and symptoms of seizures

Diagnosis & monitoringDiagnosis & monitoring

Treatment, first aid, medications, surgery, otherTreatment, first aid, medications, surgery, other

Status epilepticusStatus epilepticus


PRINCIPLES OF STAFF EDUCATIONPRINCIPLES OF STAFF EDUCATION

Fluent with seizure first aid and Fluent with seizure first aid and assessmentassessment

Awareness of what constitutes Awareness of what constitutes a neurological emergency, and a neurological emergency, and the ensuing treatment / the ensuing treatment / antiepileptic medication useantiepileptic medication use

DocumentationDocumentation

Recognize the various Recognize the various manifestations of seizuresmanifestations of seizures


STARRY STARRY NIGHT


JAPAN, 1997, POKEMONJAPAN, 1997, POKEMON


EPILEPSY FACTSEPILEPSY FACTS

Prevalence of epilepsy in the United States is 0.5% to Prevalence of epilepsy in the United States is 0.5% to 1% (2.3 million). 1.4 million (15 to 64 years), 550,000 1% (2.3 million). 1.4 million (15 to 64 years), 550,000 (>65), 300,000 (<14 years) (>65), 300,000 (<14 years)

Approximately 2% to 5% of children have febrile seizures Approximately 2% to 5% of children have febrile seizures with an age range of 3 months to 5 years. with an age range of 3 months to 5 years.

Most persons have one type of seizureMost persons have one type of seizure

80% Occur before age 2080% Occur before age 20From From Epilepsy: A Report to the NationEpilepsy: A Report to the Nation. Published in 1999 by the . Published in 1999 by the

Epilepsy FoundationEpilepsy Foundation


PATHOGENESISPATHOGENESIS

Seizure : Behavior Seizure : Behavior change associated with change associated with an an electrical discharge electrical discharge in cortex. Neurons recruit in cortex. Neurons recruit other neurons to fire, thus other neurons to fire, thus clinical manifestations are clinical manifestations are related to the number of related to the number of neurons affected & neurons affected & correlate with the focus & correlate with the focus & path of spread.path of spread.

Status epilepticus : Status epilepticus : recurring seizures with recurring seizures with incomplete recovery incomplete recovery between attacks. between attacks. Epilepsy : Two or more Epilepsy : Two or more unprovoked seizures.unprovoked seizures.Convulsion : a seizure in Convulsion : a seizure in which motor manifestations which motor manifestations predominate. predominate.


ETIOLOGYETIOLOGY

0

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seizures

symptomatic

idiopathic


Metabolic - Metabolic - drugs:drugs: amphetamines, cocaine, amphetamines, cocaine, theophylline theophylline drug withdrawaldrug withdrawal: : alcohol, sedatives, antiepileptic alcohol, sedatives, antiepileptic medications, medications, electrolyteelectrolyte: : hyponatremia, acidosis, hyponatremia, acidosis, Magnesium/Calcium /Amino Magnesium/Calcium /Amino acid disturbancesacid disturbances

Genetic / birth or development Genetic / birth or development abnormalitiesabnormalities

Infections/poisoning Infections/poisoning

Lesions /traumaLesions /trauma

Toxemia of pregnancyToxemia of pregnancy

Precipitating factors / Precipitating factors / triggers: alcohol, triggers: alcohol, hyperventilation, menses, hyperventilation, menses, flashing lights, fever, flashing lights, fever, exhaustion, nutrition, exhaustion, nutrition, sounds, psych factorssounds, psych factorsSeizure Mimics /behavior Seizure Mimics /behavior disorders, breath holding, disorders, breath holding, cardiac dysrhythmias, cardiac dysrhythmias, hyperventilation, migraine hyperventilation, migraine syndromes, movement syndromes, movement disorders, psuedo seizures, disorders, psuedo seizures, sleep disturbances, syncope, sleep disturbances, syncope, transient ischemic attack, transient ischemic attack, panic attack, psychogenic, panic attack, psychogenic, toxic/metabolic abnormalitiestoxic/metabolic abnormalities


CLASSIFICATION OF SEIZURESCLASSIFICATION OF SEIZURES

GENERALIZED GENERALIZED

(Bilateral hemisphere)(Bilateral hemisphere)

PARTIALPARTIAL

(Local onset, aura)(Local onset, aura)


GENERALIZED GENERALIZED (Bilateral hemisphere)(Bilateral hemisphere) Primary generalized seizures. Bilateral & symmetric Primary generalized seizures. Bilateral & symmetric without focal onset & usually idiopathic. Sign of “4” without focal onset & usually idiopathic. Sign of “4” exception.exception.Absence (petit mal). 2 -10 second lapse of consciousness. Absence (petit mal). 2 -10 second lapse of consciousness. Onset 4-12 y/o & decreased frequency in adolescence. Onset 4-12 y/o & decreased frequency in adolescence. Manifested by staring, eye blinking, lip smacking. Manifested by staring, eye blinking, lip smacking. Myoclonic. Quick contractions of partial, whole, or groups Myoclonic. Quick contractions of partial, whole, or groups of muscles. Single or intermittent jerk in the same or of muscles. Single or intermittent jerk in the same or different body parts. Note: not all myoclonus is epileptic. different body parts. Note: not all myoclonus is epileptic. Clonic (flexion), tonic (extension), and tonic-clonic (grand Clonic (flexion), tonic (extension), and tonic-clonic (grand mal). Abrupt loss of consciousness with tonic, clonic, or mal). Abrupt loss of consciousness with tonic, clonic, or tonic-clonic convulsion, followed by postictal confusion. tonic-clonic convulsion, followed by postictal confusion. The most common, also the most dangerousThe most common, also the most dangerousAtonic, loss of motor toneAtonic, loss of motor tone


PARTIAL (Local onset, aura)PARTIAL (Local onset, aura)Simple. Partial (focal) seizures. Consciousness is not Simple. Partial (focal) seizures. Consciousness is not impaired. Subjectively, patients are likely to experience impaired. Subjectively, patients are likely to experience déjà vu and sensory, motor, or autonomic symptoms. déjà vu and sensory, motor, or autonomic symptoms. For example, patients may note vague abdominal or For example, patients may note vague abdominal or thoracic sensations. With motor involvement, patients thoracic sensations. With motor involvement, patients are likely to exhibit hemifacial or hemibody twitching. are likely to exhibit hemifacial or hemibody twitching. Complex: Consciousness is impaired. May have Complex: Consciousness is impaired. May have automatic behaviors such as lip smacking, fumbling with automatic behaviors such as lip smacking, fumbling with clothes, or even walking. Patients are amnesic for part or clothes, or even walking. Patients are amnesic for part or the entire episode. the entire episode. Partial seizures that secondarily generalizePartial seizures that secondarily generalize


SEIZURE OBSERVATIONSEIZURE OBSERVATION

Motor movement observation predominate Motor movement observation predominate seizure documentation, but emphasis should be seizure documentation, but emphasis should be placed on key observational details such as placed on key observational details such as responsiveness. responsiveness.

Videotaped seizures & periodic retraining retain Videotaped seizures & periodic retraining retain quality of assessment skills.quality of assessment skills.


FOCAL SYMPTOMSFOCAL SYMPTOMS

Lateralizing signs assist to classify partial seizures with Lateralizing signs assist to classify partial seizures with secondary generalization: head turning, neck extension, secondary generalization: head turning, neck extension, mouth or eye deviation.mouth or eye deviation.The same type of seizure may manifest in different The same type of seizure may manifest in different symptoms between patientssymptoms between patientsSeizures are unpredictable, they may startle the Seizures are unpredictable, they may startle the observer and the observer may not see the actual observer and the observer may not see the actual beginning of the seizure until it progresses, the details beginning of the seizure until it progresses, the details may be incomplete.may be incomplete.The need to provide first aid may shift attention away The need to provide first aid may shift attention away from the observation task.from the observation task.


POSSIBLE ICTAL MANIFSTATIONSPOSSIBLE ICTAL MANIFSTATIONSEmotions: disassociated affects, negative affects, panic Emotions: disassociated affects, negative affects, panic attacks, rage, transient psychosisattacks, rage, transient psychosisGustatory affects: metallic or foul taste, burning, Gustatory affects: metallic or foul taste, burning, decaying, ammonia, overpowering perfumedecaying, ammonia, overpowering perfumeVisual: patterns, shaped, flashing lights, fully formed Visual: patterns, shaped, flashing lights, fully formed complex images, sudden distortions (metmorphosia), complex images, sudden distortions (metmorphosia), micropsia, macropsiamicropsia, macropsiaAuditory: ringing or buzzing, repetitive stereotyped Auditory: ringing or buzzing, repetitive stereotyped phrases, music, distortion, illusions of echo, alteration of phrases, music, distortion, illusions of echo, alteration of volumevolumeSomatosensory: headache, discomfort, pain, tingling, Somatosensory: headache, discomfort, pain, tingling, numbness, vertigo numbness, vertigo


POSSIBLE ICTAL MANIFSTATIONSPOSSIBLE ICTAL MANIFSTATIONS

Motor: automatisms (simple or complex), abnormal eye Motor: automatisms (simple or complex), abnormal eye movements, nystagmus, jerking, staring, twitching, movements, nystagmus, jerking, staring, twitching, repetative speech, lurring of speech, speech arrestrepetative speech, lurring of speech, speech arrestAutonomic: flushing, piloerection, perspiration, shortness Autonomic: flushing, piloerection, perspiration, shortness of breath, chest pain, palpitations, sinus tachycardia, of breath, chest pain, palpitations, sinus tachycardia, nausea, epigastric rising or sinking, incontinence, nausea, epigastric rising or sinking, incontinence, salivation, belching, coughingsalivation, belching, coughingExperiential Phenomena: Intrusive memory flashbacks, Experiential Phenomena: Intrusive memory flashbacks, illusions of familiarity (déjà vu), or unfamiliarity (jamais illusions of familiarity (déjà vu), or unfamiliarity (jamais vu), feeling of clairvoyance or of an observing presence, vu), feeling of clairvoyance or of an observing presence, mind body disassociation, derealization, mind body disassociation, derealization, depersonalization, confusion, disorientation, sense of depersonalization, confusion, disorientation, sense of profundity, illusion of possession profundity, illusion of possession


SPECIALIZED LOBULAR FUNCTION AND SPECIALIZED LOBULAR FUNCTION AND ASSOCIATED SYMPTOMSASSOCIATED SYMPTOMS

Frontal: primary motor, expressive language, executive Frontal: primary motor, expressive language, executive functions, attention, social & sexual behaviors, olfactory functions, attention, social & sexual behaviors, olfactory

Parietal: primary somatosensory cortex, integration of sensory Parietal: primary somatosensory cortex, integration of sensory output, spatial location of sensory input, guidance of output, spatial location of sensory input, guidance of proximal limb movement, body image, graphic constructionproximal limb movement, body image, graphic construction

Temporal / Limbic: primary auditory cortex, language Temporal / Limbic: primary auditory cortex, language comprehension, memory, emotioncomprehension, memory, emotion

Occipital: primary visual, perception of form, color, depth, & Occipital: primary visual, perception of form, color, depth, & mvmt.mvmt.

Right hemisphere: visuospatial functions, construction, spatial Right hemisphere: visuospatial functions, construction, spatial attention, affective speechattention, affective speech

Left hemisphere: language, fine motor control, manipulation of Left hemisphere: language, fine motor control, manipulation of numbers., linear thinking, detail orientednumbers., linear thinking, detail oriented


EEG RECORDINGEEG RECORDING

TemporalTemporal

LobeLobe

Partial Partial

SeizuresSeizures


PARTIAL COMPLEX SEIZURESPARTIAL COMPLEX SEIZURESHippocampusHippocampus



DIAGNOSTIC EVALUATIONDIAGNOSTIC EVALUATION

History & ExaminationHistory & ExaminationLaboratory investigationLaboratory investigationComputerized Computerized tomography & Magnetic tomography & Magnetic resonance imagingresonance imagingElectro encephalographic Electro encephalographic tests - Surface tests - Surface electrodes, electrodes, Nasopharyngeal or Nasopharyngeal or sphenoid leads, Cortical sphenoid leads, Cortical strip electrodes or depth strip electrodes or depth electrodeselectrodes


INTRACRANIAL DEPTH INTRACRANIAL DEPTH ELECTRODESELECTRODES


SUBDURAL GRIDSUBDURAL GRID


TREATMENTTREATMENT

Management of a Management of a convulsionconvulsion

Idiopathic (Seizure control) Idiopathic (Seizure control)

Symptomatic (Treat cause)Symptomatic (Treat cause)

AnticonvulsantsAnticonvulsants

Surgical resection, Surgical resection, disconnection, or disconnection, or augmentationaugmentation

OtherOther

DRUG THERAPYDRUG THERAPY AnticonvulsantsAnticonvulsants


INTRAVENOUS PHENYTOININTRAVENOUS PHENYTOINVesicant, (pH- 14), necrosis at site if infiltration occurs. Vesicant, (pH- 14), necrosis at site if infiltration occurs. Do not use in hand, wrist, or foot lines. Forearm Do not use in hand, wrist, or foot lines. Forearm suggested. Always affirm vein patency.suggested. Always affirm vein patency.

Rate per institution, 25mg/minute suggested. Possible Rate per institution, 25mg/minute suggested. Possible 50mg/ minute maximum.50mg/ minute maximum.

Only compatible with normal saline –precipitates with Only compatible with normal saline –precipitates with glucose contaminated line.glucose contaminated line.

Cardiovascular side effects, hypotension, bradycardia.Cardiovascular side effects, hypotension, bradycardia.

Limited stability once placed in solutionLimited stability once placed in solution..


Vesicant Infiltration, Purple GloveVesicant Infiltration, Purple Glove


MANAGEMENT OF A CONVULSION: (preictal MANAGEMENT OF A CONVULSION: (preictal state)state)

Note time of onset and durationNote time of onset and duration

Note any precipitating factorsNote any precipitating factors

Note presence of an auraNote presence of an aura

Stay in attendance, remain calm Stay in attendance, remain calm

Guide person to a safe place and remove Guide person to a safe place and remove harmful objects from surroundingsharmful objects from surroundings


MANAGEMENT OF A CONVULSION:MANAGEMENT OF A CONVULSION:(ictal state)(ictal state)

Note seizure activity: body parts, sequence, Note seizure activity: body parts, sequence, character of movementcharacter of movement

Autonomic signsAutonomic signs

Level of consciousnessLevel of consciousness

Protect from secondary injury, do not place Protect from secondary injury, do not place anything in the mouth during a seizureanything in the mouth during a seizure

Do not restrainDo not restrain


MANAGEMENT OF A MANAGEMENT OF A CONVULSION: (postictal state)CONVULSION: (postictal state)

Assess level of consciousness & maintain airway protectionAssess level of consciousness & maintain airway protectionSuction and oral airway as required, remove pillowsSuction and oral airway as required, remove pillowsNothing by mouth until fully awake, position patient on side to Nothing by mouth until fully awake, position patient on side to prevent silent aspirationprevent silent aspirationRemain in attendance with patient until stableRemain in attendance with patient until stableReassure & reorient: assess for Todd’s Paralysis.Reassure & reorient: assess for Todd’s Paralysis.Note associated injuriesNote associated injuriesConsider need for oxygen face maskConsider need for oxygen face maskContinue neurological assessmentContinue neurological assessmentMaintain bed rest until back to baselineMaintain bed rest until back to baseline


STATUS EPILEPTICUSSTATUS EPILEPTICUSRecurring seizures with Recurring seizures with incomplete recovery incomplete recovery between attacksbetween attacksEtiology: Etiology:

-known seizure disorder: -known seizure disorder: withdrawal or subtherapuetic withdrawal or subtherapuetic antiepileptic medications, antiepileptic medications, superimposed illness. superimposed illness.

-without seizure history: -without seizure history: encephalitis, intracranial bleed, encephalitis, intracranial bleed, hypoglycemia, alcohol hypoglycemia, alcohol withdrawal, cerebral traumawithdrawal, cerebral trauma


MANAGEMENT: STATUS MANAGEMENT: STATUS EPILEPTICUS- (initial 10-12 minutes) EPILEPTICUS- (initial 10-12 minutes) (MGH 2007, Status Epilepticus Protocol, Epilepsy Service)(MGH 2007, Status Epilepticus Protocol, Epilepsy Service)

Initial rapid assessment: airway, vital signsInitial rapid assessment: airway, vital signs

Monitor: oxygen saturation, electrocardiogramMonitor: oxygen saturation, electrocardiogram

Establish intravenous access & obtain laboratory tests: Establish intravenous access & obtain laboratory tests: Complete blood count, electrolytes, Blood urea Complete blood count, electrolytes, Blood urea nitrogen/Creatinine, Glucose, Calcium, Magnesium, nitrogen/Creatinine, Glucose, Calcium, Magnesium, Phosphorous, liver function tests, antiepileptic Phosphorous, liver function tests, antiepileptic medication levels, Toxicology screen, arterial blood gas medication levels, Toxicology screen, arterial blood gas

Administer intravenous Thiamine -100mg & 50% Administer intravenous Thiamine -100mg & 50% Dextrose - 50 ccDextrose - 50 cc

Lorazepam, 0.1 mg/kg IV (<2 mg/min)Lorazepam, 0.1 mg/kg IV (<2 mg/min)


MANAGEMENT : STATUS MANAGEMENT : STATUS EPILEPTICUS (within 40 minutes) EPILEPTICUS (within 40 minutes)

Phenytoin, 20mg/kg IV @ 50 mg/min. or Phenytoin, 20mg/kg IV @ 50 mg/min. or Fosphenytoin 20mg/kg IV @ 150mg/min. Fosphenytoin 20mg/kg IV @ 150mg/min. monitor electrocardiogram, assess for monitor electrocardiogram, assess for hypotension- blood pressures every 2 minuteshypotension- blood pressures every 2 minutes

Phenytoin 10mg/kg IV @ 50/min. or Phenytoin 10mg/kg IV @ 50/min. or Fosphenytoin 10mg/kg IV @ 150/min. Send Fosphenytoin 10mg/kg IV @ 150/min. Send repeat Dilantin level 20 minutes after load.repeat Dilantin level 20 minutes after load.


MANAGEMENT : STATUS MANAGEMENT : STATUS EPILEPTICUS (within 40 minutes)EPILEPTICUS (within 40 minutes)

As alternative: Valproic Acid 30mg/kg IV As alternative: Valproic Acid 30mg/kg IV @150mcg/min. or Levetiracetam 50mg/kg IV @ @150mcg/min. or Levetiracetam 50mg/kg IV @ 100mg/min100mg/min


MANAGEMENT : STATUS MANAGEMENT : STATUS EPILEPTICUS (within 60 minutes)EPILEPTICUS (within 60 minutes)

Phenobarbital 20mg/kg Phenobarbital 20mg/kg @ 75 mg/min@ 75 mg/min

Intubate, if not already Intubate, if not already donedone

Initiate Initiate electroencephalographic electroencephalographic monitoringmonitoring

Contact Neurologist/ Contact Neurologist/ Epilepsy specialistsEpilepsy specialists


MANAGEMENT : STATUS EPILEPTICUSMANAGEMENT : STATUS EPILEPTICUS

Load and titrate to stop clinical and Load and titrate to stop clinical and electroencephalographic seizures, or maintain burst electroencephalographic seizures, or maintain burst suppression on electroencephalogam. Use fluid to suppression on electroencephalogam. Use fluid to support blood pressure, add vasopressors if fluids fail. support blood pressure, add vasopressors if fluids fail.

Pentobarbital 5mg/kg IV load, then titrate (0.3-9 Pentobarbital 5mg/kg IV load, then titrate (0.3-9 mg/kg/hr, avg..= 4mg/kg/hr), ormg/kg/hr, avg..= 4mg/kg/hr), or

Midazolam 0.2 mg/kg IV, load preferred if BP is Midazolam 0.2 mg/kg IV, load preferred if BP is unstable, then titrate 0.1-0.4mg/kg/hr, or unstable, then titrate 0.1-0.4mg/kg/hr, or

Propofol 1-2 mg/kg IV load/hr, then titrate 2-10mg/kg/hrPropofol 1-2 mg/kg IV load/hr, then titrate 2-10mg/kg/hr


MANAGEMENT : STATUS MANAGEMENT : STATUS EPILEPTICUS (ideally within 48 hours)EPILEPTICUS (ideally within 48 hours)

Obtain CT scan (if clinically Obtain CT scan (if clinically indicated)indicated)

Correct underlying cause of status Correct underlying cause of status epilepticusepilepticus

Adjust the principal anticonvulsants Adjust the principal anticonvulsants to therapeutic effectto therapeutic effect

Taper Midazolam, PentobarbitaL, Taper Midazolam, PentobarbitaL, or Propofol after above is completeor Propofol after above is complete


MANAGEMENT : STATUS EPILEPTICUSMANAGEMENT : STATUS EPILEPTICUS

Care of the patient on Care of the patient on paralytics, or in paralytics, or in barbiturate coma. barbiturate coma. Associated hazards of Associated hazards of immobility - pulmonary, immobility - pulmonary, skin, GI, positioning & skin, GI, positioning & splinting, eye care, splinting, eye care, hemodynamic support & hemodynamic support & assessmentassessment

Consider antibiotics, Consider antibiotics, antiviral agents, or lumbar antiviral agents, or lumbar puncture, cool patient if puncture, cool patient if febrile, frequent lab febrile, frequent lab assessments assessments

Family support & Family support & education education


PRINCIPLES OF LONG TERM PRINCIPLES OF LONG TERM MONITORINGMONITORING

Wean from antiepileptic medicationsWean from antiepileptic medications

Capture and collect electric, visual, & auditory Capture and collect electric, visual, & auditory data on seizure events in a controlled situation. data on seizure events in a controlled situation.

Maintain safety at all timesMaintain safety at all times


DOCUMENTATIONDOCUMENTATION

Inherent in good seizure observation is good Inherent in good seizure observation is good documentation. Accurate documentation can lead to a documentation. Accurate documentation can lead to a more definitive and expedited diagnosis. Note time of more definitive and expedited diagnosis. Note time of onset and duration, precipitating factors, presence of an onset and duration, precipitating factors, presence of an aura, note seizure activity- body parts involved, aura, note seizure activity- body parts involved, sequence and character of movement, autonomic signs, sequence and character of movement, autonomic signs, level of consciousness and content of consciousness, level of consciousness and content of consciousness, neurological exam and presence of postictal deficits, or neurological exam and presence of postictal deficits, or secondary injury related to seizure activitysecondary injury related to seizure activity


DOCUMENTATIONDOCUMENTATION

1.1. Describe the beginning Describe the beginning

2.2. Describe responsivenessDescribe responsiveness

3.3. Describe movement, mobility, and toneDescribe movement, mobility, and tone

4.4. Describe sensation and perceptionDescribe sensation and perception

5.5. Describe post ictal responsesDescribe post ictal responses


DOCUMENTATION-1DOCUMENTATION-1 Describe the beginning Describe the beginning

Describe circumstances.Describe circumstances.

Describe precipitating factors.Describe precipitating factors.

Was the seizure onset observed?Was the seizure onset observed?

Was there an aura?Was there an aura?

Did the person continue, stop, or slow down their Did the person continue, stop, or slow down their activity?activity?

What happened first and how did it proceed?What happened first and how did it proceed?


DOCUMENTATION-2DOCUMENTATION-2Describe responsivenessDescribe responsiveness

Describe responses to you, self & environment.Describe responses to you, self & environment.

Describe responses, automatic or complex?Describe responses, automatic or complex?

Assess response to touch.Assess response to touch.

Assess response to auditory stimuli.Assess response to auditory stimuli.

Assess response to visual stimuli, check pupils.Assess response to visual stimuli, check pupils.


DOCUMENTATION-3DOCUMENTATION-3 Describe movement, mobility, and tone Describe movement, mobility, and tone

Was there movement or posture change?Was there movement or posture change?Was there movement of the head or eyes?Was there movement of the head or eyes?Was it unilateral or bilateral, was it symmetrical if Was it unilateral or bilateral, was it symmetrical if bilateral?bilateral?Assess whether tone is increased (rigid) or Assess whether tone is increased (rigid) or decreased (limp)?decreased (limp)?Were there any automatisms (repetitive Were there any automatisms (repetitive purposeless movements), or purposeful purposeless movements), or purposeful movements?movements?


DOCUMENTATION-4DOCUMENTATION-4Describe sensation and perceptionDescribe sensation and perception

What does the person describe or say? Ask What does the person describe or say? Ask them for a description.them for a description.

Are there any automatic signs (skin temperature Are there any automatic signs (skin temperature change, change in color, sweating)?change, change in color, sweating)?

Did they say or do anything unusual (cursing, Did they say or do anything unusual (cursing, swearing, mumbling, wandering, combative)?swearing, mumbling, wandering, combative)?


DOCUMENTATION-5DOCUMENTATION-5 Describe post ictal responses Describe post ictal responses

What were they like after the seizure?What were they like after the seizure?

How long before they were back to baseline?How long before they were back to baseline?

Could thy recall the event or what happened at Could thy recall the event or what happened at the beginning of the seizure?the beginning of the seizure?

Were there any temporary deficits?Were there any temporary deficits?

Was there any confusion or disorientation?Was there any confusion or disorientation?

Was there any bowel or bladder incontinence?Was there any bowel or bladder incontinence?


Non-epileptic seizures (NES)Non-epileptic seizures (NES)

Events that may present similar to epileptic seizures, Events that may present similar to epileptic seizures, however there is no electrographic correlate on EEGhowever there is no electrographic correlate on EEGMay be unable to determine type of seizures based on May be unable to determine type of seizures based on clinical presentation aloneclinical presentation aloneOf patients admitted to inpatient epilepsy monitoring Of patients admitted to inpatient epilepsy monitoring units, up to 40% are diagnosed with NESunits, up to 40% are diagnosed with NESMore common in females in their 30’sMore common in females in their 30’sCan also have concurrent epilepsyCan also have concurrent epilepsy


NES – Clinical featuresNES – Clinical features

Most episodes occur with a witness presentMost episodes occur with a witness presentNES tend NOT to occur during sleepNES tend NOT to occur during sleepEpisodes are often frequentEpisodes are often frequent– Most report at least daily episodesMost report at least daily episodes

Often have an incomplete loss of consciousnessOften have an incomplete loss of consciousnessAre rarely less than 1 minute, usually much longerAre rarely less than 1 minute, usually much longerMay have forced eye closureMay have forced eye closure– During true ictal events, eyes are usually openDuring true ictal events, eyes are usually open


Criteria to distinguish epileptic versus Criteria to distinguish epileptic versus psuedo seizurespsuedo seizures

DescriptionDescription EpilepticEpileptic PsuedoseizurePsuedoseizure

Apparent Apparent causecause

absentabsent Emotional disturbanceEmotional disturbance

warningwarning Varies: commonly unilateral or Varies: commonly unilateral or epigastricepigastric

Palpitations, malaise, choking, bilateral foot auraPalpitations, malaise, choking, bilateral foot aura

onsetonset Common suddenCommon sudden Often gradualOften gradual

screamscream At onsetAt onset During courseDuring course

convulsionconvulsion Rigidity followed by jerking, Rigidity followed by jerking, rarely rigid alonerarely rigid alone

Rigidity or struggling, throwing limbs and head Rigidity or struggling, throwing limbs and head aboutabout

bitingbiting tonguetongue Lips, hands, or other people or thingsLips, hands, or other people or things

micturationmicturation frequentfrequent nevernever

defecationdefecation occasionaloccasional nevernever

durationduration A few minutesA few minutes Often > 30 minutesOften > 30 minutes

terminationtermination spontaneousspontaneous Spontaneous or artificially induced (water etc)Spontaneous or artificially induced (water etc)


Psychiatric conditions with NESPsychiatric conditions with NES

- - DepressionDepression

– AnxietyAnxiety– Somatoform/conversion disorderSomatoform/conversion disorder– Post Traumatic Stress DisorderPost Traumatic Stress Disorder– Dissociative disorderDissociative disorder– Personality disorders (borderline personality, Personality disorders (borderline personality,

Obsessive Compulsive Disorder, narcissistic, Obsessive Compulsive Disorder, narcissistic, histrionic and antisocial personalities)histrionic and antisocial personalities)


Diagnosis of NESDiagnosis of NESRoutine ElectroencephalogramRoutine Electroencephalogram– Often not very usefulOften not very useful

Video Electroencephalogram Video Electroencephalogram – Gold standard for diagnosisGold standard for diagnosis

Serum testingSerum testing

Neuropsychological testingNeuropsychological testing

NeuroimagingNeuroimaging– Magnetic resonance imaging – often normal in true Magnetic resonance imaging – often normal in true

epilepticsepileptics


Presenting the diagnosis of NESPresenting the diagnosis of NES

Often is a challenge to present the diagnosis to the Often is a challenge to present the diagnosis to the patientpatient

Should emphasize that the patient is not “making it up”, Should emphasize that the patient is not “making it up”, the episodes are real, however they are not epilepsythe episodes are real, however they are not epilepsy

Stress the importance of psychiatric follow-upStress the importance of psychiatric follow-up


Treatment and Prognosis of NESTreatment and Prognosis of NESTreatment:Treatment:– Traditional psychotherapyTraditional psychotherapy– Cognitive behavioral therapy Cognitive behavioral therapy

Prognosis:Prognosis:– A minority achieve seizure-freedom (25 – 33%)A minority achieve seizure-freedom (25 – 33%)– Children do better than adults doChildren do better than adults do– Risk factors for worse prognosis include older age at Risk factors for worse prognosis include older age at

onset, lower educational level, longer duration of onset, lower educational level, longer duration of symptoms, more limited family support, male gender, symptoms, more limited family support, male gender, anger at diagnosisanger at diagnosis


REFERENCES: REFERENCES: American Association of Neuroscience Nurses, Clinical guideline series, American Association of Neuroscience Nurses, Clinical guideline series, Seizure AssessmentSeizure Assessment, , 1997.1997.DB Hoch MD, Partners neurology service, Epilepsy service- MGHDB Hoch MD, Partners neurology service, Epilepsy service- MGHEpilepsy Foundation of Massachusetts and Rhode Island. (888) 576-9996 Epilepsy Foundation of Massachusetts and Rhode Island. (888) 576-9996 MGH,Up to Date. MGH,Up to Date. Psychogenic Non-Epileptic SeizuresPsychogenic Non-Epileptic Seizures, 2008. , 2008. Misra UK, Kalita J, Patel R. Sodium valproate vs phenytoin in status Misra UK, Kalita J, Patel R. Sodium valproate vs phenytoin in status epilepticus: a pilot study. Neurology 2006 Jul 25: 67(2): 340-2.epilepticus: a pilot study. Neurology 2006 Jul 25: 67(2): 340-2.Reuters, Reuters, Abnormal Brain Response Caused Pokemon- Induced SeizuresAbnormal Brain Response Caused Pokemon- Induced Seizures, , Nature Neuroscience, 2000,3:259-263.Nature Neuroscience, 2000,3:259-263.Rowe,R. Rowe,R. Celebrating Who We Are: Famous People with EpilepsyCelebrating Who We Are: Famous People with Epilepsy, Epilepsy , Epilepsy Association, Metro Toronto, 1998:.9.Association, Metro Toronto, 1998:.9.Uges JW, van Huizen MD, Engelsman J., Wilms EB, Touv DJ, Peters E, Uges JW, van Huizen MD, Engelsman J., Wilms EB, Touv DJ, Peters E, Vecht CJ. Vecht CJ. Safety and pharmacokinetics of intravenous levetiracetuam Safety and pharmacokinetics of intravenous levetiracetuam infusion as add-on in status epilepticusinfusion as add-on in status epilepticus. Epilepsia, 2009. Mar. 50(3):415-21. . Epilepsia, 2009. Mar. 50(3):415-21. Epub 2008Epub 2008Wulf, J. Wulf, J. Evaluation of Seizure Observation and DocumentationEvaluation of Seizure Observation and Documentation, Journal of , Journal of Neuroscience Nursing, 2000, 32, 27-36.Neuroscience Nursing, 2000, 32, 27-36.

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JBFahey 3-2010 SEIZURES Jean B. Fahey MSN, RN, ACNS-BC, CCRN, CNRN Neuroscience Clinical Nurse Specialist Massachusetts General Hospital Boston, MA